Provider Demographics
NPI:1083627335
Name:FOGARTY, HEIDI TARA (LMSW)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:TARA
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 SCOTT RD
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:MI
Mailing Address - Zip Code:48074-3703
Mailing Address - Country:US
Mailing Address - Phone:810-367-7861
Mailing Address - Fax:
Practice Address - Street 1:2875 HENRY ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-2526
Practice Address - Country:US
Practice Address - Phone:810-987-9700
Practice Address - Fax:810-987-9148
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010688381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM97240004Medicare ID - Type Unspecified